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Findings

A written finding is a formal document handed down by a coroner following an investigation into a death or fire and is generally the final step in the coronial investigation process. A written finding is made regardless of whether an inquest is held or not.

A written finding following an investigation into a death will usually, if possible, include:

  • the identity of the person who died
  • the time, date, and location where the death occurred
  • a summary of the evidence relating to the circumstances of the death, in some cases
  • comments or recommendations made by the coroner aimed at preventing similar deaths, in some cases.

Findings are published when:

  • an inquest was held
  • recommendations have been made
  • a coroner otherwise orders they be published.

Findings handed down and published are available below.

Search older findings on the Australasian Legal Information Institute database (AustLII).

Please consider that it may be upsetting to read details about a death or fire in an inquest finding. Some information may be graphic or distressing.

Use the search field above to locate a finding. You can search for a name, a case number, type of death or location of death.

Any person may apply for some or all of a finding to be reviewed and/or appealed.

    Recommendations

    The Coroners Act 2008 allows a coroner to make recommendations as part of their finding following an investigation into a death or fire.

    Recommendations can be made to any Minister, public statutory authority or entity that may help prevent similar deaths. A public statutory authority or entity who receives a recommendation from a coroner must respond, in writing, within three months stating what action, if any, has or will be taken.

    The Court will publish inquest findings with recommendations and the subsequent responses below.

    Findings list

    Name Case ID Case type Date Sort ascending Coroner Related orders and rulings Responses to recommendations
    David Leslie Chapman COR 2016 2722 Finding into death without inquest 08/05/2017 Coroner Audrey Jamieson
    Wayne David Baldi COR 2016 0319 Finding into death without inquest 04/05/2017 Coroner Rosemary Carlin
    Child E COR 2015 4688 Finding into death without inquest 01/05/2017 Coroner Audrey Jamieson
    Helen Julia Mok COR 2013 1463 Finding into death with inquest 20/04/2017 Deputy State Coroner Iain West
    Suzanne Laura McIllree COR 2015 4232 Finding into death without inquest 19/04/2017 Coroner John Olle
    Lauren Pilkington COR 2016 4013 Finding into death without inquest 19/04/2017 Coroner Audrey Jamieson
    Baby Isabella Rose COR 2013 3731 Finding into death with inquest 13/04/2017 Deputy State Coroner Paresa Spanos
    Michael John Darmody COR 2014 2445 Finding into death with inquest 10/04/2017 Coroner John Olle
    Natasha Calleja COR 2015 4329 Finding into death with inquest 07/04/2017 Coroner Rosemary Carlin
    Child W COR 2011 4815 Finding into death without inquest 06/04/2017 State Coroner Judge Sara Hinchey